Third Party Administrator Location List {WC171}

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKER S COMPENSATION THIRD PARTY ADMINISTRAT OR LOCATION LIST Trading Partner Name Date Enter the FEIN and nine-digit Postal Code that will be used by your company as the SENDER ID in the Header Record of all EDI transactions. This should match infrmation submitted on o your Master Trading Partner Profile. Master FEIN Postal Code Address City, State Please provide the FEIN, Colorado Division of WorkersCom pensation TPA Code, address, and nine-digit postal code for each location of the Third Party Administrator that will be transmitting data. We will notify you of any discrepancy between the identifying information, including the mailing address and the present records of the Division of Workers Compensation. It is understood that this list will have entries added or removed from time to time. TPA FEIN Code TPA Name Address Postal Code The FEIN and the postal code must match the DN 8 and DN 14, respectively, submitted in your transmissions. Attach additional sheets as needed. WC171 7/02